Thursday, November 29, 2007

Payback Time: A Counter-Detailing We Will Go

I received many helpful suggestions for how to part with my "dirty thirty." I've decided that the most logical solution is to donate time to "counter-detailing," which is essentially the opposite of giving drug talks. Pioneered as "academic detailing" by Jerry Avornat Harvard Medical School, counter-detailing involves visiting doctor's offices and teaching about evidence-based medicine. The emphasis is on confronting the latest marketing claims of more expensive me-too medications and alerting doctors to the subtle statistical deceptions so common in pharmaceutical advertising.

Reviewing my Wyeth pay stubs, I can replicate my 2002 March of Shame through local doctor's offices and counter-detail them on my own dime. Anyone who wants a free talk for their organization can contact me at drcarlat@comcast.net. I'll do these until my 30K runs out.

By the way, several physicians at the National Physician's Alliance (NPA) are available for free talks on pharmaceutical industry influence, and they span the specialties, offering counter-detailing on treatments in internal medicine, cardiology, pediatrics, etc.... And join NPA while you're on their site. Unlike the AMA, they will never sell your name to drug companies.

I applaud this idea. But I wonder how well it will work. In my experience, teaching evidence-based medicine is not always a sure fire way to make yourself popular. So I fear that you may find it hard to find audiences for your talks, even if you give them for free.

Obviously, one problem is that you won't be accompanied by a free lunch and an attractive drug rep.

Another problem is that evidence-based medicine seems to make a lot of physicians uncomfortable. Some may be afraid it is impractical, requires too much mathematical expertise, or is a ploy by managed care or the government. But it's relatively easy to counter these fears.

But I suspect the reason it makes most people uncomfortable is that a thorough, unbiased analysis using EBM principles may prove that one's favorite drug, device, procedure, or program doesn't work as well as one would like.

Physicians (and others involved in health care) may have strong psychological reasons to believe in particular tests or treatments. These include wishful thinking, ego bias, pathophysiological reasoning, groupthink, etc. Also, in too many cases, as you know, there may be conflict of interest. So many may resist the whole notion of EBM because it is liable to to challenge their current beliefs.

I think this is an excellent idea, teaching evidence-based medicine. But I have a suggestion... Because, as we all know, even evidence-based medicine has biases, you should also throw in a few words about critical thinking and how everything should be critically evaluated, even if it shows up in the research literature.

I believe what happens more often than not isn't a conscious choice to "do the wrong thing," but a choice of pursuing the path of least resistance, which can lead to "lazy" thinking on our parts sometimes. We often need to be reminded and challenged to think more critically, especially when patient care is on the line.

BTW, I believe anyone's time if given genuinely, with determination and with integrity is worth every minute of that person's time and every minute is worth a thousand minutes of the time given by people without ethics, and though it will be hard going, IT MAKES A DIFFERENCE.

Dr. Carlat, as I enjoy your Blogs, I will like to share some words to help assuage your guilty feelings and maybe reconsider sending the money back. As in matters of Science, Business and Ethics the “Experts and Nobel Prize winners” disagree, I like to approach your dilemmas from a common sense approach. First I will address the business and ethics part, the science of drugs studies and Effexor in a later response.Not only does every action bring a reaction, but inaction also brings actions. There are always trade-off and consequences that at first impression we do not consider.As you have pointed out;1) Pharmaceutical companies are the main sponsors of CME, Specialty Journals, Conventions and University Research.2) Most experts and Chairman of the Departments in these Institutions of Learning receive compensation in one form or another from the Pharmaceutical companies.3) The previous research funding from insurance companies and government have practically disappeared.4) Family physicians and other None-Psychiatric Specialties prescribe 70% of psychotropic medications.5) Until recently most none-psychiatrist physicians received less than 2W of psychotropic training in medical school.6) Most psychotropic medications used now have been introduced after most practicing physicians have graduated.7) The FDA regulates closely and has heavily fined the Pharmaceutical Co. for the content of what Lecturers sponsored by them have said, so their Lawyers review al the slides for content so it can only address FDA-PDR approved content. The lecturers can address any questions from the audience.8) On the average it takes $800 million and 12 years to bring a new drug to the market. Most research drugs are discarded before reaching FDA approval.9) The Market demands Pharmaceutical Co. to be profitable or perish.They will use well proven marketing tools to survive, from name recognition and reminders (pens, mugs), to goodwill (lunches, friendly attractive staff, etc.10) Insurance companies do not pay for the Gym to lose weight and control BP and Diabetes, nor improve depression but they will pay for a treatment pill and for the side effects and adverse effects.11) In the days of instant 1 minute news and issue explanation, and all the technology to “save time”, pills fit in nicely in most people schedules.12) The Adversarial System creeping in all aspects of Society. You have to be for the Pharmaceutical approach or against it. Common sense tells you that this is not the case, there are many options and some activities can be discarded and others improved.Consider some of the trade-offs of not giving lectures;1) Patients suffer because they receive most of their treatment and psychotropic medications from physicians who do not have much training or will receive their training from marketing drug reps.2) If these physicians take time off for conventions to study psychotropics and not cardiac medication, the lectures they receive will be sponsored by the same pharmaceutical companies you are shunning anyway.3) While the FDA and the Pharma lawyers want you to stay within the approved indications, there is no prohibition for you to say what you believe about other products, and FDA encourages fair and balance presentations.4) You can do your presentation and if the company does not like what you say they will not offer any more talks. If they do then you are serving a great purpose of informing other physicians.5) Other pharmaceutical companies can hire you, as it seems you prefer SSRI, and you can educate other physicians in these products. We do not expect GM to hire people to educate or market to the public how good Ford products are.6) Let not throw out the baby with the bath water. Before we prohibit pharmaceutical companies from peddling their products let be sure other mechanism for continuing education are in place. I think most physicians know that the sponsor Drug lectures are biased and process the information accordingly. It was the no full disclosure and ghost writing that has to stop. Your reviews are good!In summary, the same way you pick and choose the information you read in the Psychiatric journals full of Pharmaceutical ad’s, or read some of the Internet articles,(Medscape, Web-MD) with ads of the same products in the information article, pick and choose your Pharma talks.Full disclosure; I have a company BHS that specializes in psychiatric/MH education and unfortunately the only one’s willing to pay to help educate others are Pharmaceutical Co. My services are well received but insurance, manage care , Vitamins, Natural herbs, exercise nor nutritional programs, Gyms, therapists, self help organizations or companies, etc are not paying for education. Hum! I wonder why is medications used as first line? Well, here is another place were you can release your 30,000 guilt; my company will educate people of your choice about the subject of your choice! Ironic isn’t it.Keep up the good work, I enjoy your Blogs. I have further explored these themes in my book, The Return of Common Sense, or in my Website (still under construction), www.commonsense-mentalhealth.com.Comment by CSFELIX - November 29, 2007 at 1:25 pm

I was wondering how long you think it will take you to "work off" the 30K, and how you are calculating the worth of your time, is this in years or months?

I also may not sound like a professional,I'm not, but wanted to say something that I can relate to, and possibly most consumers-- what if Dr. Carlat doesn't have the 30K to pay back?

Everyone assumes he's got 30K floating for a free for all give away. If that is the case, then I say cut a check for 10%;donate it to a local food bank, then volunteer your time until the cows come home.Because unless you YouTube it, no one will ever know where you've done your time, or if it even mattered.

I say, just admit you made the 30K, and forget about restitution and reconciliation. No one will care in a week.

Tuition income from all medical students in all medical schools is much less than 3 billion dollars per year. If we erased medical student debt in return for a future binding social contract involving participation in all government insurance plans and total removal of all conflicts of interest, we would have a much more efficient medical system.

We have the most heavily indebted medical students and the most expensive medical system in the world. There is a connection.

Heavily indebted medical students and alumni are more likely to be mercenary regardless of specialty choice. These habits are likely to persist over a lifetime. Untoward cooperation with pharmaceutical companies is one of the dysfunctional aspects of our health care system. We need doctors who are educated and independent. Medical education without debt would attract a better medical student candidate and would educate a better medical doctor.

Thirty thousand dollars would have paid for the annual tuition of one medical student.

Perhaps, Dr. Carlot use that $30,000 to publicize the corroding influence of medical student debt.

Ignore the naysayers, Danny. $30K worth of counter-detailing is infinitely more valuable than anything that amount could be used to purchase.

Roy: True, he won't be bringing lunch, but in lieu of the drug rep/art history major, he could bring ME, a psych nurse. Though I've often been mistaken for a drug rep (I'm kind of a babe), it's clear from the moment I speak that I am a medical professional.

John Mack: I have two words for you: Rosa Parks.It's your kind of "if you can't beat 'em, join'em" defeatist attitude that has caused this malignant proliferation in the first place.

bill: Yours is the kind of wisdom that the medical world needs more of. Keep speaking truth to power.

anonymous: NO, they won't just pick up a book. That almost universal trait is what gets drug reps into physicians offices.

Stephany: Even if he does have the 30K, there is no better atonement for him than this, for many reasons, the most important of which is that HE will remember this in a week. And so will I, because Carlat doesn't know it yet, but he'll be taking a road trip to upstate New York.

That was kind of my point. The general media hyped public won't care in a week. What we do for others off-blog time, is what many ppl. never read about. I guess what I was trying to say, is repay it the way he chooses, without need for announcement. For example, if I broke ground on a Soteria House tomorrow, my goal would be the shovel in my hand, and an invisible person holding it. That's just me. Behind the scenes I am sure there are many professionals with names on anon walls of gifts of time or money.

I feel he did not need to announce attonement.

I appreciate the candid discussion. I have also been mistaken for a pharma rep&nurse.